The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Answer and Explanation

The Correct Answer is D

A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.

B. 2+: This indicates normal reflexes, not brisk.

C. 1+: This indicates diminished or hypoactive reflexes, not brisk.

D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.

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Correct Answer is C

Explanation

A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.

B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.

C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.

A. Head and face B. Mouth and throat C. Mental status examination D. Ears

Correct Answer is A

Explanation

A. Head and face: Cranial nerve VII (facial nerve) controls the muscles of facial expression, so its motor function is assessed by examining the movement of the face, such as smiling, frowning, or raising eyebrows.

B. Mouth and throat: While cranial nerve VII does innervate some muscles involved in facial expressions that might affect the mouth, a more comprehensive assessment of its motor function occurs in the head and face region.

C. Mental status examination: This assesses cognitive functions rather than specific motor functions of cranial nerves.

D. Ears: The assessment of cranial nerve VII does not typically involve the ears.

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The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

A positive Murphy's sign is indicative of?

Correct Answer is C

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Correct Answer is A

Explanation

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Which general survey question focuses on the common "fifth vital sign"?

When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

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